Provider Demographics
NPI:1679853634
Name:GREEN, KATIE E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATIE
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:E
Other - Last Name:KRUPKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:457 JACK MARTIN BLVD.
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724
Mailing Address - Country:US
Mailing Address - Phone:732-840-7500
Mailing Address - Fax:732-840-2088
Practice Address - Street 1:457 JACK MARTIN BLVD.
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-840-7500
Practice Address - Fax:732-840-2088
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014932-1363AM0700X
NJ25MP00367400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical